Sunday, March 16, 2014

Insel's Techno-Utopia

In a recent post, 1BOM likened the key opinion leaders (KOLs) in psychiatry who gathered at two glitzy meetings to fashion commentators at the Oscars:
It was Dr. Schatzberg’s comment at the end, "More needs to be done now if we are to have new treatments in the next decade..." It sounded to me like those dress designers thinking about what new innovations they could muster for the coming year. It has to be something new – novel, innovative, a new look, a new material, a new something to drape the pretty ladies with on the red carpet next year. […]

The psychopharmacology era from 1987 to the recent past has been like that. The next wonderful new antidepressant has to be more desirable than the last one. The novel way of accessorizing [sequencing, combining, augmenting] has to be value added. Without a pipeline producing something new periodically, the shine wears off of the old drugs and their foibles begin to show. So we need a new design, a new line [as they say in the garment industry], something to keep the momentum flowing. But our KOLs haven’t been like the dress designers, they’ve been more like the Red Carpet commentators who talk about other peoples’ designs – giving talks like recent advances in …, or neurobiology of ..., or writing review articles, or signing on to the industrial clinical trials – more groupies than stars. That must be why they’re so frantic. Commentators with nothing to comment about.
I think that's an interesting analogy, but for me it doesn't quite hit the nail on the head. To me, a more apt analogy is along ideological lines. Lately I've been reading Steven Pinker's The Better Angels of Our Nature, a very detailed and data-driven book about why violence has declined over time. I was struck by the following passages about the roles of utopian ideologies in promoting violence:
Institutionalized torture in Christendom was not just an unthinking habit; it had a moral rationale. If you really believe that failing to accept Jesus as one's savior is a ticket to fiery damnation, then torturing a person until he acknowledges this truth is doing him the biggest favor of his life; better a few hours now than an eternity later. And silencing a person before he can corrupt others, or making an example of him to deter the rest, is a responsible public health measure. [p. 16-17]
Revolutionary and Napoleonic France, Bell has shown, were consumed by a combination of French nationalism and utopian ideology. The ideology, like the versions of Christianity that came before it and the fascism and communism that would follow it, was messianic, apocalyptic, expansionist, and certain of its own rectitude. And it viewed its opponents as irredeemably evil: as existential threats that had to be eliminated in pursuit of a holy cause. [p. 239]
Of course, none of these KOLs are like Napoleon, Stalin, Mao, etc. Thank the deity of your choice that they do not have that much power, and that we live in a much more peaceful time. These days, scathing editorials questioning a person's integrity are as dirty as the KOLs get.

But just like those utopian movements, much of academic psychiatry (especially the KOL segment) is driven by an ideology: the tenets of biopsychiatry, which the 1 Boring Old Man blog has described in detail. This ideology is assumed to be correct, and because its believers think that this system will result in a huge amount of good (i.e. "NIMH envisions a world in which mental illnesses are prevented and cured"), then people who seem to oppose this ideology are at best deeply misguided, at worst causing irrevocable harm. Furthermore, anything short of this grand vision is deemed not worth pursuing.

In my mind, this is the best explanation for why things like Paxil study 329, or the Markingson case, or problematic conflicts of interest, or millions of mentally ill being locked up in jails and prisons, get ignored by the leaders of academic psychiatry. They're seen as relatively insignificant bumps in the road in the grand utopian scheme. Last year, I wrote a somewhat tongue-in-cheek post about what if the NIMH succeeds in its utopian vision. With the recent news that the NIMH will only fund treatment studies that also examine biological etiology, things are much more serious than I thought.